PA Accident and Health Insurance
All of these are considered sources of information that can assist an underwriter in determining whether or not to accept a risk EXCEPT
National Association of Insurance Underwriters
what is the purpose of the PA Life and Health Insurance Guaranty Association ?
Provide policy owner protection if an insurer becomes insolvent
Premiums paid that exceed 7 1/2% of an insured's Adjusted Gross Income (AGI) are tax-deductible when paid for which of the following plans?
qualified long term care plan
the role of the federal government was expanded when Medicaid was established by allowing by allowing the State to
receive matching funds to expand public assitance programs
The purpose of the Coordination of Benefits provision in group accident and health plans is to
avoid over-payment of claims
Why are dividends from a mutual insurer not subject to taxation?
because dividends are considered to be a return of premium
which situation would qualify an individual for receiving benefits from a qualified long term care policy?
becoming cognitively impaired (mentally ill)
a disability income policy can prevent an insured from earning a higher income than they were working by utilizing
benefit limits
a disability policy owner is injured and becomes totally disabled. The benefits pay for 2 years starting from the date of the injury. What is this time period called?
benefit period
an insured has a health plan that pays an established amounts in accordance with a list of injuries, surgical procedures, or other losses. this list is called
benefit schedules
Ted has a health insurance plan that requires him to pay a specific sum out of pocket before any benefits are paid in a calendar year. Which of these does his health plan have?
calendar year deductible
What is issued to each employee of an employer health plan?
certificate
all of the following are included as part of a contact in the entire contract provision EXCEPT
changes made by the producer
all of the following are elements of an insurance policy EXCEPT
claim forms
in which of the following processes will the insurer oversee the insured's hospital stay to confirm everything is going accordingly to schedule and that the insured will be released as planned?
concurrent review
in an insurance contract the element that shows each party is giving something of value is called
consideration
in order for a contact to be valid, it must
contain an offer and acceptance
_____ is NOT an element of a valid contract
countersignature
which of the following is not true regarding a critical illness plan
coverage is limited to a single devastating disease
Jennifer is required to pay a specific sum out of pocket before any benefits are paid in a year. Her health policy most likely contains a(n)
deductible
Medicare Part B covers
doctor's charges
What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)?
dread disease insurance
a medicare supplement policy must NOT contain benefits which
duplicate medicare benefits
all of these are characteristics of a major medical expense policy EXCEPT
elimination periods
Which prohibited act involves a producer spending a client's insurance premiums for his/her own personal use?
embezzlement
when soliciting insurance, a producer CANNOT
emphasize Guaranty Association benefits
Under group health insurance, a certificate of coverage is issued to the
employee
all of the following are qualifications for establishing a health savings account (HSA) EXCEPT
enrolled in a health plan with a prescription drug benefit
a field underwriter's main task is to
ensure an applicant's medical info is accurate and complete
the waiting period for a disability insurance policy
excludes payments for a short term illness and injury
which of the following is required to maintain a producer's licensee in Pennsylvania
field underwriter, who solicits insurance and earns commission
Violations of US Code Title 18 section 1033, may result in
fine and/or imprisonment
which of the following is NOT included in comprehensive major medical plans?
first-dollar coverage
a medicare supplement plan can be cancelled by the insurer
for non payment of premiums
a group disability income plan that pays tax-free benefits to covered employees is considered
fully contributory
a health insurance policy that allows an insurer to change the policy owner's premium
guaranteed renewable policy
the commissioner has the right and duty to
audit insurer financial reports and conduct market studies
In Pennsylvania, a Specified disease accident and health plan must provide a minimum benefit in the amount of
$5,000
Every Pennsylvania insurer, upon receiving notification of a claim, must acknowledge receipt of the notice within
10 days
How many employees must an employer have for a terminated employee to be eligible for COBRA
20
a licensed producer must report any administrative action taken against the licensee in another jurisdiction or by another agency department in PA within how many days of the final disposition?
30 days
in a long term care policy the right to examine period is
30 days
within how many days must the producer report to the commissioner any changes made against him/her?
30 days
As of January 1, 2014, an employer with up to 25 full time equivalent (FTE's) with average annual wages of less than $50,000 may be eligible for a tax credit of ___ of the premiums paid by the employer.
50%
No Long-Term Care policy may exclude pre-existing conditions for a period of more than
6 months
in Pennsylvania, an employee must request spousal coverage under a group sponsored accident and health plan within __________ days of marriage
60 days
In an employer-sponsored contributory group Disability Income plan, the employer pays 60% of the premium and each employee pays 40% of the premium. Any income benefits paid are taxed to the employee at
60% of the benefit
Which of the following is INELIGIBLE to participate in a Section 125 Plan?
An S-Corp Owner with a greater than 2% share
how is medicare part b (supplementary medical insurance) funded
General tax revenue and user premiums
Which type of coverage pays an amount per day for hospitalization directly to the insured regardless of the insured's other health insurance?
Hospital Indemnity
an employer is issued a group medical insurance policy. This single contract is known as
Master Policy
what is the contract called that is issued to an employer for a Group Medical insurance plan?
Master policy
Mark continues working after the age of 65 and is covered through his employer's group health plan. Which of the following statements is TRUE?
Medicare is the secondary payer
This MANDATORY health policy provision states that the policy, including endorsements and attached papers, constitutes
The entire insurance contract between the parties
which of the following nursing home options would BEST suit an individual who needs care and supervision but NOT full-time care?
assisted living facilities
HIPPA considers which of the following as "individually identifiable health information?
a person's health claim information
A plan in which an employer pays insurance benefits from a fund derived from the employer's current revenues is called
a self funded plan
after the passage of the medigap law in 1990 what was developed by the NAIC?
a standardized model Medicare Supplement Policy
Under a disability income policy, which provision would be payable if the cause of an injury is unexpected and accidental?
accidental bodily injury provision
holding premium funds for timely submission to the insurer is an example of
acting in a fiduciary capacity
Group dental plans will frequently place a limit on annual benefits in order to minimize
adverse selection
people with higher loss exposure have the tendency to purchase insurance more often than those of average risk. this is called
adverse selection
which of the following do coordination of benefits allow
allows the secondary payer to reduce their benefit payments so no more than 100% of the claim is paid
loss of income insurance provides
an individual the means to replace wages
a licensee may only sell, solicit, and negotiate insurance contracts on behalf of the
appropriating insurer
the difference between a long term care partnership and a non-partnership plan is which of the following?
asset protection
Bill requires some nursing care and supervision but NOT full-time care. Which of these nursing home options would best serve him?
assisted living
Credit Accident and Health plans are designed to
help pay off existing loans during periods of disability
which of the following is NOT included under a health benefit plan
hospital indemnity plan
sharing 50% of producer's commission with the insured is an example of
illegal inducement
which of the following actions may an insurance company NOT do in a health policy that contains a guaranteed renewable premium benefit ?
increase premiums on an individual basis
When a producer offers something of value in return for the purchase of an insurance policy, which prohibited sales practice has been committed?
inducement
Health insurance will typically cover which of the following perils?
injury due to accident
which of the following is present when an applicant stands to lose value if the insured dies?
insurable interest
who is responsible for assembling the policy forms or insureds?
insurance carriers
an accident and health policy that provides reimbursement benefits makes them payable to the
insured
An applicant's character and personal habits can be obtained for underwriting purposes from which source?
investigators consumer report
which of the following statements regarding Group Disability income insurance is true?
it provides benefits for nonoccupational illnesses and injuries
Without a Section 125 Plan in place, what would happen to an employee's payroll contribution to an HSA?
it would be considered taxable income to the employee
a common exclusion with Vision Plan is
lasik surgery
which contract is insurable interest a component of?
legal purpose
Someone needing custodial care at home would require which type of coverage?
long term care
The election of COBRA for continuation of health coverage will
maintain the same coverage and increase premium
which of the following is considered to be a point of service (POS) plan?
managed care plan
In contrast to a guaranteed renewable policy, a noncancellable policy
may never raise premiums
the focus of major medical insurance is providing coverage for
medical and hospitalization expenses
which of these is likely to occur when life or health insurance is being applied for
medical history from the insured may be reviewed and reported
which of these gaps in medicare coverage is addressed with medicare supplemental insurance ?
medicare in-hospital deductible
what is the required action to be taken by Pennsylvania licensee before operating under an assumed business name?
notify commissioner
Paul is an employee who caught a disease unique to the trade in which he was exposed to. Paul has a(n)
occupational disease
what makes an insurance policy a unilateral contract
only the insurer is legally bound
Richard owns an insurance policy that is renewable only at the option of the insurance company. His policy is considered to be
optionally renewable
the document that describes policy features, benefits, exclusions, and riders in a long term care policy is known as the
outline of coverage
Which clause defines total disability as being unable to perform the major duties of the insured's regular occupation?
own occupation clause
what kind of life insurance policy issued by a mutual insurer provides a return of divisible surplus?
participating life insurance policy
states that have "no loss no gain" laws require a replacing policy
pay for ongoing claims under the policy it replaces
which of the following would evidence ownership in a participating health insurance contract?
policy ownership
An insured applicant with a below average likelihood of loss is typically considered to be a
preferred risk
a rehabilitation benefit is intended to
prepare the insured to return to employment
a health insurance policy will typically cover
preventative health services
which of the following provides Medicare supplement policies?
private insurance companies
who can receive an insurance commission?
producer
what is required before an insurance producer can act as a representative of an insurer?
producer needs to be appointed by that insurer
when comparing an HMO to a PPO, the PPO
provides a greater choice of providers
according to the affordable care act, what metal tier is required to have an actuarial value of 70% with covered individuals paying 30% through deductibles, co-pays, and other cost sharing features?
silver plan
generally speaking, which three levels of care are Long-Term Care policies provided with
skilled nursing, intermediate, and custodial care
which of the following is NOT a type of Medicare Advantage Plan
socical security disability income
in an insurance contract,the applicant's "consideration" is the
statements made in the application and the premium
An insurer's claim settlement practices are regulated by the
states insurance departments
distributions from a Health Savings Account (HSA) for qualified medical expenses are
tax-free
which of the following decisions would a Health Savings Account (HSA) owner not be able to make
the amount contributed by the employer
when a preferred provider organization (PPO) insured goes out of network which of the following actions occur?
the insurer will pay a reduced amount
under the affordable care act, a large employer that does NOT provide health insurance owes an employer mandate penalty MUST pay an annual penalty, which is calculated by multiplying $2,000 by
the number of full times employees minus 30
under a contract of adhesion
the terms must be accepted OR rejected in full
Legal purpose is a term used in contract law meaning
there must be legal reasons for entering into the contract
which of the following is the purpose of medical cost management ?
to control health claim expenses
Insurance represents the process of risk
transference
when an insurance company consistently fails to provide reasonable explanations for the denial of a claim, this is called an..
unfair claim settlement
at what point does a self-insured group qualify for stop-loss coverage?
when claims exceed a specified limit in a set period of time
How is a health provider reimbursed if they do NOT have an agreement in place with the insurance company?
with a usual, customary, and reasonable fee
Pennsylvania law requires that an insurer must notify the Commissioner of a producer appointment termination
within 30 days of termination